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ShadowHealth HEENT Tina Jones
1. Is your throat sore?: Reports sore throat
2. Is your throat itchy?: Reports itchy throat
3. Are your eyes itchy?: Reports itchy eyes
4. Do you have a runny nose?: Reports runny nose
5. How long has your throat been sore?: began 1 week ago
6. When did your nose start running?: began 1 week ago
7. When did your eyes start itching?: began 1 week ago
8. is the throat pain constant: constant throat pain
9. when does your throat pain feel the worst: worse in morning
10. does it hurt when you swallo: soreness with swallowing
11. rate throat pain on 1-10 scale: mild to moderate throat discomfort
12. how often does your nose run: constant runny nose
13. does your nose itch: denies
14. do you have sinus pain: denies
15. do you have sinus pressure: no
16. are you sneezing: no
17. what color is your mucus: clear
18. is the mucus thick: thin mucus
19. does your mucus have pus in it: denies
20. do your eyes constantly itch: constant itching
21. are your eyes red: reports eye redness
22. have you had changes in your breathing: not affected
23. do you have a cough: denies
24. do you have chest tightness: denies
25. have you been wheezing: denies
26. has your asthma worsened: denies
27. do you know what is causing your symptoms: allergy like symptoms
28. do you think you have a cold: no cold symptoms
29. do you think you're having an allergic reaction: similar symptoms to sister's hay fever
30. have you treated your eyes with anything: denies
31. have you done anything for your runny nose: denies
32. have you taken any antihistamines: denies
33. have you taken any decongestants: denies
51. have you been exposed to secondhand smoke: denies exposure to secondhand smoke
52. when was your last vision exam: childhood
53. when was your last hearing exam: childhood
54. when was your last dental visit: within the last 2 years
55. how often did you see the dentist when you were a child: reguarly
56. do you have dental insurance: denies
57. do you have vision insurance: denies
58. are you allergic to cats: confirms
59. are you allergic to dust: confirms
60. do you have seasonal allergies: denies
61. have you been sick recently: denies
62. do you have chills: denies
63. do you have fever: denies
64. have you felt fatigued: low energy level
65. have you felt nauseous: denies nausea or vomiting
66. do you ever get headaches: occasional headaches
67. do you have a headache currently: denies
68. have you ever had a head injury: denies
69. do you get lightheadedness: denies
70. how often do you have headaches: once a week
71. how long do your headaches last: few hours
72. how would you describe your headaches: tight and throbbing
73. where do you feel your headaches: behind her forehead
74. how would you rate your headache on a scale of 1-10: 3 or 4
75. how do you treat your headaches: Tylenol
76. what causes your headaches: reading and studying
77. do you have blurry vision: occasionally
78. has your vision worsened: confirms
79. do you have eye pain: denies
80. do you have dry eyes: denies
81. do you wear contacts: denies
82. can you describe your blurry vision: fuzzy letters
83. when do you get blurry vision: when reading for long periods
84. how long have you been reading when your vision gets blurry: after 2+ hours of
101. do you have jaw problems: denies
102. do you have any current dental problems: denies
103. what dental problems have you had: cavities as a kid
104. do you get strep throat often: denies
105. do you have problems with your lymph nodes: denies
106. do you have a history of throat problems: denies
107. have you noticed any changes to your voice: denies
108. do you have any tonsil problems: denies
109. do you have any neck pain: denies
110. do you have family members with allergies: sister with hay fever
111. do vision problems run in the family: denies
112. do sinus problems run in the family: denies
113. do ear or hearing problems run in the family: denies
114. do mouth, throat, or gland problems run in your family: denies
115. do headaches or migraines run in your family: denies
116. head and face:
symmetric papules, pustules, or come dones excessive hair growth
red, chapped nose
117. eyes and orbital area: no visible abnormal findings
moist and pink white sclera no discharge
118. nasal cavity: pale,
bluish patent clear discharge no abnormal findings
119. right ear:
pink no abnormal findings no discharge pearly gray 5:00 cone of light
120. left ear:
pink no abnormal findings no discharge pearly gray 7:00 cone of light
121. mouth and throat: moist and pink
1+ tonsils cobblestoning edema
133. right fundal exam: cotton wool
bodies sharp disc margin
134. left fundal exam: no
abnormalities sharp disc margin
135. visual acuity: right:
20/40 left: 20/
136. weber, rinne, whisper, gag: normal
normal normal intact
137. subjective: HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of
sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges which has "helped a little". She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose "runs all day" and is clear discharge. She has not attempted any treatment for her nasal symptoms. She states that her eyes are constantly itchy and she has not attempted any eye specific treatment. She denies cough and recent illness. She has had no exposures to sick individuals. She denies changes in her hearing, vision, and taste. She denies fevers, chills, and night sweats. She has never been diagnosed with seasonal allergies, but does note that her sister has "hay fever". Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma or headaches. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. •
Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week.
138. objective: General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute dis- tress. She is
alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses.
- Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit.
- Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough.
139. assessment: Allergic Rhinitis
140. plan: Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated
factors and bring log to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to increase intake of water and other fluids and educate on frequent handwashing. • Educate on avoidance of triggers and known allergens • Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever. • Revisit clinic in 2-4 weeks for follow up and evaluation.
